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Re-evaluating consensus and uncertainty among treatment options for early onset scoliosis: a 10-year update

  • Consensus Study
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A Correction to this article was published on 28 September 2022

This article has been updated

Abstract

Purpose

Consensus and uncertainty in early onset scoliosis (EOS) treatment were evaluated in 2010. It is currently unknown how treatment preferences have evolved over the past decade. The purpose of this study was to re-evaluate consensus and uncertainty among treatment options for EOS patients to understand how they compare to 10 years ago.

Methods

11 pediatric spinal surgeons (similar participants as in 2010) were invited to complete a survey of 315 idiopathic and neuromuscular EOS cases (same cases as in 2010). Treatment options included the following: conservative management, distraction-based methods, growth guidance/modulation, and arthrodesis. Consensus was defined as ≥ 70% agreement, and uncertainty was < 70%. Associations between case characteristics and consensus for treatments were assessed via chi-squared and multiple regression analyses. Case characteristics associated with uncertainty were described.

Results

Eleven surgeons [31.7 ± 7.8 years of experience] in the original 2010 cohort completed the survey. Consensus for conservative management was found in idiopathic patients aged ≤ 3, whereas in 2010, some of these cases were selected for surgery. There is currently consensus for casting idiopathic patients aged 1 or 2 with moderate curves, whereas in 2010, there was uncertainty between casting and bracing. Among neuromuscular cases with consensus for surgery, arthrodesis was chosen for patients aged 9 with larger curves.

Conclusion

Presently, preferences for conservative management have increased in comparison to 2010, and casting appears to be preferred over bracing in select infantile cases. Future research efforts with higher levels-of-evidence should be devoted to elucidate the areas of uncertainty to improve care in the EOS population.

Level of evidence

Level V.

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Data availability

The data that support the findings of this study are available from the corresponding author, HM, upon reasonable request.

Code availability

Not applicable.

Change history

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Funding

This work was conducted without the support of additional funding.

Author information

Authors and Affiliations

  1. Department of Orthopedic Surgery, Boston Children’s Hospital, Boston, MA, 02115, USA

    Hiroko Matsumoto, Brian D. Snyder, David P. Roye, John B. Emans & Michael G. Vitale

  2. Department of Orthopaedic Surgery, Harvard Medical School, Boston, MA, 02115, USA

    Hiroko Matsumoto, Brian D. Snyder & John B. Emans

  3. Department of Orthopedic Surgery, Morgan Stanley Children’s Hospital of New York Presbyterian, Columbia University Irving Medical Center, 3959 Broadway, CHONY 8-N, New York, NY, 10032, USA

    Adam N. Fano & Theodore Quan

  4. Department of Orthopaedic Surgery, University of California San Diego, San Diego, CA, 92037, USA

    Behrooz A. Akbarnia

  5. Pediatric Specialists of Virginia, Fairfax, VA, 22031, USA

    Laurel C. Blakemore

  6. Division of Orthopaedics, Children’s Hospital of Philadelphia, Philadelphia, PA, 19104, USA

    John M. Flynn

  7. Department of Orthopaedics, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA

    David L. Skaggs

  8. Department of Orthopaedics, University of Utah, Salt Lake City, UT, 84113, USA

    John T. Smith

  9. Division of Pediatric Orthopaedics, Johns Hopkins University, Baltimore, MD, 21287, USA

    Paul D. Sponseller

  10. Department of Orthopaedics, University of Arkansas for Medical Sciences and Arkansas Children’s Hospital, Little Rock, AR, 72205, USA

    Richard E. McCarthy

  11. Department of Orthopedic Surgery, Cincinnati Children’s Hospital, Cincinnati, OH, 45229, USA

    Peter F. Sturm

  12. Division of Pediatric Orthopaedic Surgery, New York-Presbyterian Morgan Stanley Children’s Hospital, Columbia University Irving Medical Center, New York, NY, 10032, USA

    David P. Roye & Michael G. Vitale

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  1. Hiroko Matsumoto
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  2. Adam N. Fano
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  4. Behrooz A. Akbarnia
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Contributions

HM, ANF, TQ,BA, LB, JF, DS, JS, BS, PS, RM, PS, DR, JE, MGV; Made substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data, or the creation of new software used in the work. HM, ANF, TQ,BA, LB, JF, DS, JS, BS, PS, RM, PS, DR, JE, MGV; Drafted the work or revised it critically for important intellectual content. HM, ANF, TQ,BA, LB, JF, DS, JS, BS, PS, RM, PS, DR, JE, MGV; Approved of the version to be published. HM, ANF, TQ,BA, LB, JF, DS, JS, BS, PS, RM, PS, DR, JE, MGV; Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Corresponding author

Correspondence to Hiroko Matsumoto.

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Conflict of interest

Dr. Blakemore reports personal fees from Stryker outside the submitted work. Dr. Matsumoto reports personal fees from Pediatric Spine Foundation, grants from Scoliosis Research Society, grants from Pediatric Orthopaedic of North America outside the submitted work. Dr. McCarthy reports personal fees from Medtronic and OrthoPediatrics outside the submitted work. Dr. Skaggs reports personal fees from Biomet, personal fees from Grand Rounds, personal fees from Orthobullets, and grants from Growing Spine Foundation outside the submitted work. Dr. Sponseller reports personal fees from DePuy Synthes, personal fees from OrthoPediatrics, and personal fees from Nuvasive outside the submitted work. Dr. Sturm reports personal fees from Nuvasive and DePuy Synthes outside the submitted work. Dr. Vitale reports non-financial support from Pediatric Spine Foundation, during the conduct of the study; grants from Setting Scoliosis Straight Foundation, grants and other from Children’s Spine Foundation, grants from Orthopaedic Scientific Research Foundation, grants and other from POSNA, other from OMeGA, personal fees from Stryker, personal fees from Biomet, personal fees from Nuvasive outside of the submitted work. The other authors have no conflicts of interest to disclose.

Ethical approval

This study was approved by the participating sites and by the Columbia University Institutional Review Board under protocol AAAS6106. It was performed in accordance with the ethical standards of the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.

Consent to participate

This study qualifies for a waiver of consent because it is a survey of surgeons and does not involve patient participation. There is no potential to adversely affect the rights or welfare of subjects since this is a survey to gather surgeon opinion, with no patient data being collected or intervention being tested.

Consent for publication

No patient identifying information is included in the article. Not applicable.

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The original online version of this article was revised: In this article the academic degrees of authors Adam N. Fano and Theodore Quan had been erronously included as part of their names.

Appendix 1: Characteristics of cases with treatment consensus and uncertainty

Appendix 1: Characteristics of cases with treatment consensus and uncertainty

Case characteristics

Treatment consensus

Treatment uncertainty

Idiopathic Scoliosis

 Age of 1, 2, 3, 6, or 9 yearrs; Cobb angle of 30°, 60°, or 90°; 0°, 15°, or 30° curve progression in the past 6 months; normal or hyperkyphosis; flexible or rigid curve

Conservative

 

 Age of 6 years*; Cobb angle of 60° or 90°; 0°, 15°, or 30° curve progression in thepast 6 months; normal or hyperkyphosis; flexible or rigid curve

Distraction

 

 Age of 6 years; Cobb angle of 60° or 90°; 0°, 15°, or 30° curve progression in the past 6 months; hyperkyphosis; rigid curve

TGR

 

 Age of 6 yrs; Cobb angle of 60° or 90°; 0°, 15° or 30° curve progression in last 6 mo; normokyphosis, flexible or rigid curve

MCGR

 

 Age of 6 yrs; Cobb angle of 90°; 30° curve progression in last 6 mo; normokyphosis, flexible curve

Spine-based

 

 Age of 6 years; Cobb angle of 60° or 90°; 0°, 15°, or 30° curve progression in the past 6 months; normal or hyperkyphosis; rigid curve

Rib-based

 

 Age of 9 years; Cobb angle of 60°; 0°, 15°, or 30° curve progression in the past 6 months; hyperkyphosis; flexible curve

Growth guidance

 

 Age of 9 years; Cobb angle of 60°; 15° or 30° curve progression in the past 6 months; normokyphosis; flexible curve

Growth modulation

 

 Age of 9 years; Cobb angle of 60° or 90°; 0°, 15°, or 30° curve progression in the past 6 months; normal or hyperkyphosis, flexible or rigid curve

 

Growth guidance-arthrodesis

 Age of 9 years; Cobb angle of 60°; 0° of curve progression in the past 6 months; normokyphosis; flexible curve

 

Conservative-surgical

 Age of 6 or 9 years; Cobb angle of 60°; 0°, 15°, or 30° curve progression in the past 6 months; normokyphosis; rigid curve

 

No treatment preference

 Age of 1, 2, 3, or 6 years; Cobb angle of 30°; 0° curve progression in the past 6 months; normal or hyperkyphosis; flexible or rigid curve

 

Observation-bracing

 Age of 6 yrs; Cobb angle of 90°; 0°, 15°, or 30° curve progression in last 6 mo; hyperkyphosis; flexible curve

 

TGR-Rib/spine-MCGR-spine/Spine

 Age of 6 years; Cobb angle of 90°; 0°, 15°, 30° curve progression in the past 6 months; normokyphosis; flexible or rigid curve

 

MCGR-Rib/spine-MCGR-spine/spine

 Age of 6 years; Cobb angle of 90°; 0°, 15°, 30° curve progression in the past 6 months; hyperkyphosis; flexible curve

 

TGR-MCGR

 Age of 6 years; Cobb angle of 90°; 0°, 15°, or 30° curve progression in the past 6 months; normal or hyperkyphosis; flexible or rigid curve

 

Rib-based-spine-based distraction

 Age of 1, 2, 3, or 6 yrs; Cobb angle of 30°; 0° curve progression in last 6 mo; normal or hyperkyphosis; flexible or rigid curve

 

Observation-intervention

Neuromuscular Scoliosis

 Hypertonic or hypotonic/myopathic; age of 3, 6, or 9 years; Cobb angle of 30° or 60°; 0°, 15°, or 30° curve progression in the past 6 months; normal or hyperkyphosis; flexible or rigid curve; respiratory impairment or no respiratory impairment; poor or normal nutritional status; chest wall involvement or no chest wall involvement

Conservative

 

 Hypertonic or hypotonic/myopathic; age of 3, 6, or 9 years; Cobb angle of 60° or 90°; 0°, 15°, or 30° curve progression in the past 6 mo; normal or hyperkyphosis; flexible or rigid curve; respiratory impairment or no respiratory impairment; poor or normal nutritional status; chest wall involvement or no chest wall involvement

Distraction

 

 Hypotonic/myopathic; age of 3 years; Cobb angle of 90°; 15° or 30° curve progression in the past 6 months; hyperkyphosis; flexible curve; respiratory impairment; normal nutritional status; chest wall involvement

VEPTR

 

 Hypertonic or hypotonic/myopathic; age of 3, 6, or 9 years; Cobb angle of 60° or 90°; 0°, 15°, or 30° curve progression in the past 6 mo; normal or hyperkyphosis; flexible or rigid curve; respiratory impairment or no respiratory impairment; poor or normal nutritional status; chest wall involvement or no chest wall involvement

MCGR

 

 Hypertonic or hypotonic/myopathic; age of 6 or 9 years; Cobb angle of 60° or 90°; 15° or 30° curve progression in the past 6 months; normal or hyperkyphosis; flexible or rigid curve; respiratory impairment or no respiratory impairment; poor or normal nutritional status; chest wall involvement or no chest wall involvement

Spine-based

 

 Hypertonic or hypotonic/myopathic; age 3 or 6 years; Cobb angle of 60° or 90°; 0°, 15°, or 30° curve progression in the past 6 months; normal or hyperkyphosis; flexible or rigid curve; respiratory impairment or no respiratory impairment; poor or normal nutritional status; chest wall involvement or no chest wall involvement

Rib-based

 

 Hypertonic or hypotonic/myopathic; age of 9 years; Cobb angle of 60° or 90°; 0°, 15°, or 30° curve progression in the past 6 mo; normal or hyperkyphosis; flexible or rigid curve; respiratory impairment or no respiratory impairment; poor or normal nutritional status; chest wall involvement or no chest wall involvement

Arthrodesis

 

 Hypertonic or hypotonic/myopathic; age of 6 or 9 years; Cobb angle of 60°; 0° or 15° curve progression in the past 6 months; normokyphosis; flexible or rigid curve; respiratory impairment or no respiratory impairment; poor or normal nutritional status; chest wall involvement or no chest wall involvement

 

Conservative-distraction

 Hypertonic; age of 9 yrs; Cobb angle of 60° or 90°; 0° or 15° curve progression in last 6 mo; hyperkyphosis; flexible or rigid curve; respiratory impairment or no respiratory impairment; poor or normal nutritional status; chest wall involvement or no chest wall involvement

 

Conservative-arthrodesis

 Hypertonic or hypotonic/myopathic; age of 9 years; Cobb angle of 60° or 90°; 0°, 15°, 30° curve progression in the past 6 mo; normal or hyperkyphosis; flexible curve; respiratory impairment; poor or normal nutritional status; chest wall involvement or no chest wall involvement

 

Distraction-arthrodesis

 Hypertonic or hypotonic/myopathic; age of 6 or 9 years; Cobb angle of 60° or 90°; 0° or 15° curve progression in the past 6 mo; normal or hyperkyphosis; flexible or rigid curve; respiratory impairment or no respiratory impairment; poor or normal nutritional status; chest wall involvement or no chest wall involvement

 

Conservative-surgical

 Hypertonic or hypotonic/myopathic; age of 3, 6, or 9 years; Cobb angle of 60° or 90°; 0°, 15°, 30° curve progression in the past 6 months; normal or hyperkyphosis; flexible or rigid curve; respiratory impairment or no respiratory impairment; poor or normal nutritional status; chest wall involvement or no chest wall involvement

 

No treatment preference

 Hypertonic or hypotonic/myopathic; age of 3, 6, or 9 years; Cobb angle of 30° or 60°; 0°, 15°, 30° curve progression in the past 6 months; normal or hyperkyphosis; flexible or rigid curve; respiratory impairment or no respiratory impairment; poor or normal nutritional status; chest wall involvement or no chest wall involvement

 

Observation-bracing

 Hypertonic; age of 6 years; Cobb angle of 60°; 0° or 15° curve progression in the past 6 months; normokyphosis; rigid curve; respiratory impairment; poor nutritional status; chest wall involvement

 

Observation-MCGR-Rib/Pelvis

 Hypertonic; age of 9 years; Cobb angle of 60° or 90°; 0° or 15° curve progression in the pst 6 months; hyperkyphosis; flexible or rigid curve; respiratory impairment or no respiratory impairment; poor or normal nutritional status; chest wall involvement or no chest wall involvement

 

Observation-Arthrodesis

 Hypertonic or hypotonic/myopathic; age of 9 years; Cobb angle of 60° or 90°; 0°, 15°, or 30° curve progression in the past 6 months; normal or hyperkyphosis; flexible curve; respiratory impairment; poor or normal nutritional status; chest wall involvement or no chest wall involvement

 

MCGR-Spine/Pelvis-arthrodesis

 Hypertonic; age of 6 years; Cobb angle of 90°; 0° curve progression in the past 6 months; normokyphosis; flexible curve; respiratory impairment; poor nutritional status; chest wall involvement

 

Rib-based-Spine-based Distraction

 Hypertonic or hypotonic/myopathic; age of 3, 6, or 9 years; Cobb angle of 30°, 60°, or 90°; 0°, 15°, 30° curve progression in the past 6 months; normal or hyperkyphosis; flexible or rigid curve; respiratory impairment or no respiratory impairment; poor or normal nutritional status; chest wall involvement or no chest wall involvement

 

Observation-intervention

 Hypertonic or hypotonic/myopathic; age of 6 or 9 yrs; Cobb angle of 60° or 90°; 0° or 15° curve progression in last 6 mo; normal or hyperkyphosis; flexible or rigid curve; respiratory impairment or no respiratory impairment; poor or normal nutritional status; chest wall involvement or no chest wall involvement

 

Observation-surgical

 Hypertonic or hypotonic/myopathic; age of 6 or 9 years; Cobb angle of 60°; 0° or 15° curve progression in the past 6 months; normokyphosis; flexible or rigid curve; respiratory impairment or no respiratory impairment; poor or normal nutritional status; chest wall involvement or no chest wall involvement

 

Observation-MCGR

  1. *In bold are characteristics specifying a subgroup of the variables presented

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Matsumoto, H., Fano, A.N., Quan, T. et al. Re-evaluating consensus and uncertainty among treatment options for early onset scoliosis: a 10-year update. Spine Deform 11, 11–25 (2023). https://doi.org/10.1007/s43390-022-00561-1

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